Partners for Patriots Service Dog Application Today's Date * MM DD YYYY Referred By * Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Gender * M F Height * Weight * Marital Status * Single Married Divorced Home Phone (###) ### #### Cell Phone * (###) ### #### Email * Nearest Relative Not Living in the home * Relationship * Address of Nearest Relative * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone of Nearest Relative (###) ### #### Cell Phone of Nearest Relative * (###) ### #### Names and ages of people living in the home * Do you work outside the home? * Yes No Will the dog go to work with you and be safe to do so? Yes No List the names of caregivers, if any, who will help you on a daily basis List any other pets living in the home (example: Black Lab - female - spayed) * Equipment Required Please check the equipment you use: Wheelchair (Manual) Wheelchair (Power) Crutches Hearing Aid Cane Prosthesis Wrist Braces Walker Leg Brace 3-Wheel Electric Scooter Other (please detail in notes) Please describe what you would like a service dog to do for you * Can you or your family or caregivers provide the care for the dog? * Yes No Dogs need a lot of exercise. Are you are do you have someone available to exercise the dog or do you have a treadmill? * I can exercise the dog I have someone available to exercise the dog I have a treadmill Monthly cost to care for a dog can run about $175.00 with feed, heartworm preventative, flea & tick control and Veterinarian care. Are you able to afford the cost? * Yes No Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Right Hand Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Left Hand Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Right Arm Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Left Arm Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Right Leg Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Left Leg Strengh Assessment: Rate your physical strengh on a scale of 1 to 10. 1 - Least 10 - Most * Upper Body Does anyone living in the household have allergies to dogs? * Yes No Describe your personality and attitude towards life. * Branch of the Military * Air Force Army Marines Navy Other Notes: Please provide any additional information * Please type your name as an electronic signature for this application * Thank you!
